Quality Improvement Reports

Improved access and targeting of musculoskeletal services in northwest Wales: targeted early access to musculoskeletal services (TEAMS) programme

BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7478.1325 (Published 02 December 2004) Cite this as: BMJ 2004;329:1325
  1. Peter Maddison (peter.maddison{at}nww-tr.wales.nhs.uk), consultant rheumatologist1,
  2. Jeremy Jones, consultant rheumatologist1,
  3. Anne Breslin, nurse specialist in rheumatology1,
  4. Craig Barton, directorate manager for surgery1,
  5. Joyce Fleur, nurse specialist in pain management1,
  6. Rhian Lewis, consultant in pain management1,
  7. Luke McSweeney, consultant orthopaedic surgeon1,
  8. Carys Norgain, therapy services manager1,
  9. Sara Smith, consultant in pain management1,
  10. Carolyn Thomas, TEAMS coordinator1,
  11. Chris Tillson, general practitioner2
  1. 1 North West Wales NHS Trust, Ysbyty Gwynedd, Bangor LL57 2PW, Wales
  2. 2 Gwynedd Local Health Board, Eryldon, Caernarfon, Wales
  1. Correspondence to: P Maddison
  • Accepted 4 August 2004


Problem The hospital based musculoskeletal service in northwest Wales was unable to cope with the demand for referrals from general practitioners. Waiting times were long, duplicate referrals to other departments were common, and general practitioners were reluctant to refer patients with common problems because of the perceived lack of service. Many referrals were made to the inappropriate specialty, especially orthopaedics. At least part of this problem was due to a lack of coordination between the four hospital departments providing musculoskeletal services and the emphasis on district general hospital based rather than community provision.

Design Review over 18 months of impact of the targeted early access to musculoskeletal services (TEAMS) programme on accessibility to musculoskeletal services.

Setting Northwest Wales.

Key measures for improvement Number of patients referred and seen with musculoskeletal problems, waiting times, number of duplicate referrals, and surgery conversion rates in orthopaedic clinics.

Strategies for change Establishing with central clinical triage a common pathway for all musculoskeletal referrals so that patients attend the appropriate department. A back pain pathway led by extended scope physiotherapists was developed, and general practitioners with special interests and extended scope physiotherapists were trained to provide services for patients with uncomplicated musculoskeletal problems in the community.

Effects of change Over 18 months the number of referrals more than doubled. Despite this, waiting times for musculoskeletal services fell; this was noticeable for rheumatology and pain management. Duplicate referrals were abolished. Surgery conversion rates did not, however, change. Questionnaires from the clinics showed a high level of patient satisfaction.

Lessons learnt Integration of hospital services that traditionally have worked in isolation can result in greatly improved access to musculoskeletal services. Community based multidisciplinary clinics run by specially trained general practitioners with special interests and extended scope physiotherapists are an effective way of managing patients with uncomplicated musculoskeletal problems and have been well received by patients and general practitioners. The huge unmet burden of need was reflected by the great increase in musculoskeletal referrals. Other approaches are needed to meet this, including better education of general practitioners and methods for identifying and modifying psychosocial risk factors for chronic pain at an early stage.


  • Contributors PJM was the lead writer of this paper; he is guarantor. The other authors are members of the Targeted Early Access to Musculoskeletal Services Project Group and contributed to the design of the programme, its implementation and monitoring, and the preparation of this report.

  • Funding Innovations in care programme for orthopaedics, Welsh Assembly government, and North Wales NHS Trust.

  • Competing interests None declared.

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